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SAN JOAQUII )UNTY ENVIRONMENTAL HEALTH 1 ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />� A5 STA T LQIJ <br />1ti�tREQUEES_TE1D:en�. <br />x.11 <br />COMMENTS: CACCEPTED <br />FACILITY ID # <br />ERVICE REQUEST # <br />oo � a-�12 (� <br />PSR <br />OWNER / OPERATOR <br />CHECK It BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDRESS <br />Kc) UiLL u'e- <br />SITEADDRESS <br />Street Number <br />Oire ion <br />-Wa- <br />reel Name <br />cit <br />G ZI <br />HOME or MAILING ADDRESS (If Different from Site Address) s� t 8 <br />Street Number <br />Z5f6nf-"ap t4QJ JZ�- <br />Street NaMe <br />CITY <br />ZIP <br />STATE 0,4i oU <br />PHONE#1 Ext' <br />(9,35)X67 - 4707 <br />APN# LAND USE APPLICATION# <br />PHONE #2 Er. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR `, ,eL <br />1ti�tREQUEES_TE1D:en�. <br />x.11 <br />COMMENTS: CACCEPTED <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAMEA t_ 1 14 L � <br />Fi tJL'�-.. T <br />DATE: <br />PHONE # <br />'t <br />ExT <br />a -l3 -- 4:03 $ <br />HOME or MAILING ADDRESS <br />Kc) UiLL u'e- <br />Date Service Completed (if already completed): <br />FAX <br />( `6) <br />-Wa- <br />CITY '5a -LA- -JO a <br />STATE CA <br />ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:U tIs. X u • - � DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT lA4ti.il)�lQ((,C-Q LJi C <br />IjAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br />provided to me or my representative. <br />TYPE OF SERVICE V 5 v i t C,& <br />1ti�tREQUEES_TE1D:en�. <br />x.11 <br />COMMENTS: CACCEPTED <br />BY: BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid 77FTayment <br />Date <br />Payment Type <br />Invoice It <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />